— 生理適應 · MEDIUM · MCQ —
一位病人的胸管脫落，護理師應採取的最優先措施為何？
A nurse is caring for a client with a chest tube that has become dislodged. Which action is the priority?
- AApply a sterile occlusive dressing taped on three sides✓ 正解貼上三邊固定的無菌密封敷料
- BReinsert the chest tube immediately立即重新插入胸管
- CAssess the client for a tension pneumothorax評估病人是否有張力性氣胸
- DCall the physician通知醫師
— Explanation · 中文詳解 —
胸管脫落（Chest tube dislodgement）是急症。當胸管滑出，空氣會經由傷口進入胸膜腔，導致張力性氣胸（Tension pneumothorax），這是致命的呼吸循環衰竭。護理師必須立即使用三邊封閉敷料（Occlusive dressing），此敷料具備單向閥機制：吸氣時敷料會因負壓吸附在傷口上防止空氣進入，吐氣時則允許胸腔內多餘空氣排出，以維持生理安全。
A dislodged chest tube creates an open pneumothorax risk, which can rapidly progress to a life-threatening tension pneumothorax. The priority nursing action is to apply a sterile occlusive dressing taped on three sides to act as a one-way valve, preventing air from entering the pleural space while allowing trapped air to escape.